Primary Nursing Diagnosis

Pain (chronic and acute) related to the effects of tumor invasion and surgical incision

OUTCOMES. Comfort level; Pain control behavior; Pain: Disruptive effects; Pain level

INTERVENTIONS. Pain management; Analgesic administration; Positioning; Teaching: Prescribed activity/exercise; Teaching: Procedure/treatment; Teaching: Prescribed medication

H PLANNING AND IMPLEMENTATION Collaborative

Surgery, radiotherapy, and chemotherapy are the major treatment modalities for pancreatic cancer. A distal pancreatectomy, used more often with islet cell tumors than with exocrine cancer, removes only the tail of the pancreas or the tail and part of the body. The spleen is also removed. A total pancreatectomy or a pancreatoduodenectomy (Whipple procedure) is used when cure is the objective. In a total pancreatectomy, the entire pancreas and spleen are removed. The Whip-ple procedure involves removal of the head of the pancreas, distal stomach, gallbladder, pancreas, spleen, duodenum, proximal jejunum, and regional lymph nodes. The procedure induces exocrine insufficiency and insulin-dependent diabetes. A pancreatojejunostomy, hepaticoje-junostomy, and gastrojejunostomy are performed with the Whipple procedure to reconstruct the gastrointestinal (GI) system. A vagotomy is usually done in both procedures to decrease the risk of peptic ulcer.

Careful postoperative management is essential for providing comfort and reducing surgical mortality. Observe vital signs, prothrombin times, drainage from drains, and wounds for signs of infection, hemorrhage, or fistula formation. Report immediately any evidence of increasing abdominal distension; shock; hematemesis, bloody stools; or bloody, gastric, or bile-colored drainage from incision sites. Vitamin K injections and blood components may be needed.

Pancreatic Cancer 691

Monitor GI drainage from the nasogastric (NG) or gastrostomy tubes carefully. These tubes are strategically placed during surgery to decompress the stomach and prevent stress on the anastomosis sites. Maintain the tube's patency by preventing kinks or dislodgment; maintain suction at the prescribed level (usually low continuous suction for an NG tube). Secure gastrostomy tubes in a dependent position. Monitor the color, consistency, and amount of drainage from each tube. The presence of serosanguineous drainage is expected, but clear, bile-tinged drainage or frank blood could indicate disruption of an anastomosis site and should be reported immediately. Do not irrigate the NG or gastrostomy tube without specific orders. When irrigation is ordered, gently instill 10 to 20 mL of normal saline solution to remove an obstruction.

Because postoperative nutritional requirements for adequate tissue healing approximate 3000 calories per day, parenteral hyperalimentation is often ordered. Monitor the blood and urine glucose levels every 6 hours, and administer insulin as needed. Once oral food and fluids are allowed, the patient is placed on a bland, low-fat, high-carbohydrate, high-protein diet. Administer pancreatic enzyme supplements (pancrelipase [Viokase, Cotazym] and lipase for metabolism of long-chain triglycerides) with each meal and snack. Observe and report any evidence of diarrhea or frothy, floating, foul-smelling stools (an indication of steatorrhea) because an adjustment in the enzyme replacement therapy may be needed.

A combination of adjuvant chemotherapy and radiation therapy with surgery may increase survival time 6 to 11 months. Most patients receive chemotherapy and radiation therapy on an outpatient basis. Palliative surgical procedures can be used to relieve the obstructive jaundice, duodenal obstruction, and severe back pain that are characteristic of advanced disease.

Pharmacologic Highlights

Medication or Drug Class

Dosage

Description

Pancreatic enzyme supplements

Varies with drug Varies with drug

Gemcitabine; fluorouracil (5-FU); cisplatin; irinotecan, paclitaxel; capecitabine; oxaliplatin; streptozocin

Pancrelipase; lipase

Kills cancer cells

Aid in digestion of proteins, carbohydrates, and fats

Postoperative Drugs: Narcotic analgesics delivered via a patient-controlled analgesic device or an epidural catheter are usually ordered. Monitor the patients response to these devices, and encourage their usage to maintain pain at a tolerable level. Administer prophylactic antibiotics as ordered.

Independent

Provide emotional support and information as treatment goals and options are explored. Patients newly diagnosed with pancreatic cancer are often in shock, especially when the disease is diagnosed in the advanced stages. Encourage the patient and family to verbalize their feelings surrounding the diagnosis and impending death. Allow for the time needed to adjust to the diagnosis, while helping the patient and family begin the grieving process. Assist in the identification of tasks to be completed before death, such as making a will; seeing specific relatives and friends; or attending an approaching wedding, birthday, or anniversary celebration. Urge the patient to verbalize specific funeral requests to family members.

692 Pancreatic Cancer

Help family members identify the extent of physical home care that is realistically required by the patient. Arrange for visits by a home health agency. Suggest the family seek supportive counseling (hospice, grief counselor), and if necessary, make the initial contact for them. Local units of the American Cancer Society offer assistance with home care supplies and support groups for patients and families.

Following any surgical procedure, direct care toward preventing the associated complications. Use the sterile technique when changing dressings and emptying wound drainage tubes. Place the patient in a semi-Fowler position to reduce stress on the incision and to optimize lung expansion. Help the patient turn over in bed, and perform coughing, deep-breathing, and leg exercises every 2 hours to prevent skin breakdown and pulmonary and vascular stasis. Teach the patient to splint the abdominal incision with a pillow to minimize pain when turning or performing coughing and deep-breathing exercises. As soon as it is allowed, help the patient get out of bed and ambulate in hallways three to four times each day. Be alert for the sudden onset of chest pain or dyspnea (or both), which could indicate the presence of a pulmonary embolism.

As the disease progresses and pain increases, large doses of narcotic analgesics may be needed. Instruct the patient on the effective use of the pain scale and to request pain medication before the pain escalates to an intolerable level. Consider switching as-needed pain medication to an around-the-clock dosing schedule to keep pain under control. Encourage the patient and family to verbalize any concerns about the use of narcotics, and stress that drug addiction is not a consideration.

Diabetes 2

Diabetes 2

Diabetes is a disease that affects the way your body uses food. Normally, your body converts sugars, starches and other foods into a form of sugar called glucose. Your body uses glucose for fuel. The cells receive the glucose through the bloodstream. They then use insulin a hormone made by the pancreas to absorb the glucose, convert it into energy, and either use it or store it for later use. Learn more...

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